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Accumulator - View By Claim

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Health Center:

Pharmacy:

Capture Date :

To:

			Health Center	Pharmacy	ShipTo	Claim Type	RX Number	Member ID	Fill	Fill Date	Adjud Date	Captured Date	NDC	Drug Name	Strength	Form	Pkg Size	QTY Disp	Curr QTY	% of Claim	Status	Status Date	Order	Wholesaler Invoice
False	2933914		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779859	MR00389502	00	02/11/2021	02/11/2021	02/12/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	30	30	100.00000	Replenished		1001811232	987509358
False	3956567		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783022	MR00145513	00	07/01/2021	07/01/2021	07/02/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	30	30	100.00000	Replenished		1001884259	3060456965
False	4086975		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783441	MR00210929	00	07/20/2021	07/20/2021	07/21/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	90	30	33.33300	Replenished		1001891615	3062304712
False	4093677		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783441	MR00210929	00	07/20/2021	07/20/2021	07/21/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	90	30	33.33300	Replenished		1001891615	3062304712
False	4093678		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783441	MR00210929	00	07/20/2021	07/20/2021	07/21/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	90	30	33.33400	Replenished		1001891615	3062304712
False	4199208		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783786	MR00145513	00	08/04/2021	08/04/2021	08/05/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	30	30	100.00000	Replenished		1001899595	3063713218
False	4467999		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784616	MR00145513	00	09/08/2021	09/08/2021	09/09/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	30	30	100.00000	Replenished		1001921174	3067195910
False	4806750		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785661	MR00210929	00	10/20/2021	10/20/2021	10/26/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	90	30	33.33300	Replenished		1001948371	3071858707
False	4810480		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785661	MR00210929	00	10/20/2021	10/20/2021	10/26/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	90	30	33.33300	Replenished		1001948371	3071858707
False	4810481		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785661	MR00210929	00	10/20/2021	10/20/2021	10/26/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	90	30	33.33400	Replenished		1001948371	3071858707